Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 011516 | GA |
NPI | 1114958410 |
---|---|
Provider Name | Michael M Carson SR. |
First Address | Suffolk, VA 23434-9296 |
Second Address | Norfolk, VA 23511-2803 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2006 |
Last Update Date | 08/07/2007 |